Burch Colposuspension versus Fascial Sling to Reduce Urinary Stress Incontinence

Division of Urology, University of California, San Diego, San Diego, CA 92103-8897, USA.
New England Journal of Medicine (Impact Factor: 55.87). 06/2007; 356(21):2143-55. DOI: 10.1056/NEJMoa070416
Source: PubMed


Many surgical procedures are available for women with urinary stress incontinence, yet few randomized clinical trials have been conducted to provide a basis for treatment recommendations.
We performed a multicenter, randomized clinical trial comparing two procedures--the pubovaginal sling, using autologous rectus fascia, and the Burch colposuspension--among women with stress incontinence. Women were eligible for the study if they had predominant symptoms associated with the condition, a positive stress test, and urethral hypermobility. The primary outcomes were success in terms of overall urinary-incontinence measures, which required a negative pad test, no urinary incontinence (as recorded in a 3-day diary), a negative cough and Valsalva stress test, no self-reported symptoms, and no retreatment for the condition, and success in terms of measures of stress incontinence specifically, which required only the latter three criteria. We also assessed postoperative urge incontinence, voiding dysfunction, and adverse events.
A total of 655 women were randomly assigned to study groups: 326 to undergo the sling procedure and 329 to undergo the Burch procedure; 520 women (79%) completed the outcome assessment. At 24 months, success rates were higher for women who underwent the sling procedure than for those who underwent the Burch procedure, for both the overall category of success (47% vs. 38%, P=0.01) and the category specific to stress incontinence (66% vs. 49%, P<0.001). However, more women who underwent the sling procedure had urinary tract infections, difficulty voiding, and postoperative urge incontinence.
The autologous fascial sling results in a higher rate of successful treatment of stress incontinence but also greater morbidity than the Burch colposuspension. ( number, NCT00064662 [] .).

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Available from: Charles W Nager, Feb 10, 2015
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    • "A major trial where autologous sling was compared to Burch colposuspension for treatment of SUI was known as the SISTEr trial. In the sling group, 48 % of women suffered a UTI compared to 32 % in the Burch group during the first 24 months of follow-up [40]. In a further study in the Medicare population, where 1,356 sling procedures were analysed, a UTI developed in 33.6 % of women within 3 months of surgery [44]. "
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    ABSTRACT: Pelvic organ prolapse (POP) and urinary tract infection (UTI) are important problems, estimated to affect around 14 and 40 % of women, respectively, at some point in their lives. Positive urine culture in the presence of symptoms is the cornerstone of diagnosis of UTI and should be performed along with ultrasound assessment of postvoid residual (PVR) in all women presenting with POP and UTI. PVR over 30 mL is an independent risk factor for UTI, although no specific association with POP and UTI has been demonstrated. The use of prophylactic antibiotics remains controversial. The major risk factors for postoperative UTI are postoperative catheterisation, prolonged catheterisation, previous recurrent UTI and an increased urethro-anal distance-suggesting that global pelvic floor dysfunction may play a role.
    Full-text · Article · Sep 2014 · Current Bladder Dysfunction Reports
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    • "All participants provided written informed consent. SISTEr randomized 655 women with predominant SUI to either an autologous rectus fascial sling or the Burch colposuspension [6]. The UITN Trial of Mid- Urethral Slings (TOMUS) study randomized 597 women to retropubic versus transobturator midurethral slings for SUI [5]. "
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    ABSTRACT: Objective. To determine baseline variables associated with urgency urinary incontinence (UUI) in women presenting for stress urinary incontinence (SUI) surgery. Methods. Baseline data from two randomized trials enrolling 1,252 women were analyzed: SISTEr (fascial sling versus Burch colposuspension) and TOMUS (retropubic versus transobturator midurethral sling). Demographic data, POP-Q measures, and validated measures of symptom severity and quality of life were collected. Charlson Comorbidity Index (CCI) and Patient Health Questionnaire-9 were measured in TOMUS. Multivariate models were constructed with UUI and symptom severity as outcomes. Results. Over two-thirds of subjects reported bothersome UUI at baseline. TOMUS patients with more comorbidities had higher UDI irritative scores (CCI score 0 = 39.4, CCI score 1 = 42.1, and CCI score 2+ = 51.0, P = 0.0003), and higher depression scores were associated with more severe UUI. Smoking, parity, prior incontinence surgery/treatment, prolapse stage, and incontinence episode frequency were not independently associated with UUI. Conclusions. There were no modifiable risk factors identified for patient-reported UUI in women presenting for SUI surgery. However, the direct relationships between comorbidity level, depression, and worsening of UUI/urgency symptoms may represent targets for preoperative intervention. Further research is necessary to elucidate the pathophysiologic mechanisms that explain the associations between these medical conditions and bladder function.
    Full-text · Article · Nov 2013 · Advances in Urology
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    • "Our decision to base treatment efficacy on the pad test was driven by the frequency and consistency with which that test was reported in the literature. Use of the pad test as an accepted measure of success is supported by its use as an outcome by three major multicenter RCTs for surgical treatments [9–12]. Although consistency of objective outcome measures is lacking, measures tend to result in similar conclusions: a procedure that is efficacious when measured with the pad test is also efficacious when measured with leak-point pressure. "
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    ABSTRACT: Stress urinary incontinence (SUI) is a common and growing problem among adult women and affects individuals and society through decreased quality of life (QoL), decreased work productivity, and increased health care costs. A new, nonsurgical treatment option has become available for women who have failed conservative therapy, but its cost effectiveness has not been evaluated. This study examined the cost effectiveness of transurethral radiofrequency microremodeling of the female bladder neck and proximal urethra compared with synthetic transobturator tape (TOT), retropubic transvaginal tape (TVT) sling, and Burch colposuspension surgeries for treating SUI. A Markov model was used to compare the cost effectiveness of five strategies for treating SUI for patients who had previously failed conservative therapy. The strategies were designed to compare the value of starting with a less invasive treatment. The cost-effectiveness analysis was conducted from the health care system perspective. Efficacy and adverse event rates were obtained from the literature; reimbursement costs were based on Medicare fee schedule. The model cycle was 3 months, with a 3-year time horizon. Single-variable sensitivity analyses were conducted to assess stability of base-case results. Two of the five strategies employed the use of transurethral radiofrequency microremodeling and achieved 17-30 % lower mean costs relative to their comparative sling or Burch strategies. Superior safety and cost effectiveness are recognized when patients are offered a sequential approach to SUI management that employs transurethral radiofrequency microremodeling before invasive surgical procedures. This sequential approach is consistent with treatment strategies for other conditions and offers a solution for women with SUI who want to avoid the inherent risks and costs of invasive continence surgery.
    Full-text · Article · Oct 2013 · International Urogynecology Journal
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